Provider Demographics
NPI:1215910666
Name:DUPONT, SUE A (PT ATC)
Entity type:Individual
Prefix:MRS
First Name:SUE
Middle Name:A
Last Name:DUPONT
Suffix:
Gender:F
Credentials:PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4223 SE 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-8400
Mailing Address - Country:US
Mailing Address - Phone:239-540-3837
Mailing Address - Fax:
Practice Address - Street 1:4223 SE 3RD AVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-8400
Practice Address - Country:US
Practice Address - Phone:239-540-3837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2016-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 11530225100000X
FLAL2712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY66882Medicare ID - Type Unspecified